Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Dr Kate Woodman
Providing the best medicine: summary of the evidence in support of breast (milk) feeding in neonatal units
Published by NHS Health Scotland
1 South Gyle CrescentEdinburgh EH12 9EB
© NHS Health Scotland 2017
All rights reserved. Material contained in this publication may not be reproduced in whole or part without prior permission of NHS Health Scotland (or other copyright owners).While every effort is made to ensure that the information given here is accurate, no legal responsibility is accepted for any errors, omissions or misleading statements.
NHS Health Scotland is a WHO Collaborating Centre for Health Promotion and Public Health Development.
This resource may also be made available on request in the following formats:
0131 314 5300
This report should be cited as: Woodman K. Providing the best medicine: summary of the evidence in support of breast (milk) feeding in neonatal units. Edinburgh: NHS Health Scotland; 2017.
For further information about this publication please contact
Dr Kate Woodman
Email: [email protected]
1
Contents About this briefing ............................................................................................ 2
The Scottish context ........................................................................................ 3
Introduction ...................................................................................................... 5
The relevance of the Health Care Quality Strategy ambitions to the experience of breastfeeding/breast milk feeding in neonatal units ................... 6
Identifying the evidence ................................................................................... 7
The impact of premature delivery..................................................................... 8
Adapting to the neonatal unit environment ..................................................... 13
The importance of breast milk and expressing .............................................. 15
Mothers’ motivation to breastfeed/breast milk feed in the neonatal unit......... 18
Coping strategies in response to breastfeeding/breast milk feeding in the neonatal unit .................................................................................................. 24
Peer support in the neonatal unit ................................................................... 32
The need to get home .................................................................................... 36
The cost-effectiveness of providing breast milk for preterm infants ............... 38
Providing donor human milk in the neonatal unit ........................................... 40
The benefits of kangaroo mother care in the neonatal unit ............................ 41
Relevant Scottish and international policy documents ................................... 43
Acknowledgements ........................................................................................ 45
References .................................................................................................... 46
Appendix 1: Guide to the Baby Friendly Initiative standards (UNICEF, December 2012). ........................................................................................... 51
Appendix 2: Support for family-centred care .................................................. 62
2
About this briefing This briefing provides a summary of the best available evidence about
breastfeeding/breast milk feeding in neonatal units (NNUs).* It is based on a
rapid review of the evidence that was undertaken in 2014/15. It is intended to
be of use to practitioners, policy makers and academics.
While there are many types of evidence, in this paper we have drawn on the
strongest evidence of the highest quality from reviews/collections of papers
published by organisations that have clear, quality assured processes, such
as the National Institute for Health and Care Excellence (NICE) or the Health
Technology Assessment programme (HTA). In addition, single (mostly
qualitative) studies that have been published in peer-reviewed journals about
parent and staff experiences of breast (milk) feeding in neonatal units have
been included.†
* The term neonatal unit (NNU) has been used throughout this summary to refer to all types of unit described above. † Full details of the evidence that has informed this paper are provided in the References.
3
This evidence briefing should be read in conjunction with the Guide to the
Baby Friendly Initiative standards (www.unicef.org.uk/wp-
content/uploads/sites/2/2014/02/Baby_Friendly_guidance_2012.pdf, also
Appendix 1) and the Family-centred model of care (see Appendix 2).
The Scottish context Several key issues are highlighted in this review of the published evidence
which emphasises the utmost importance of breastfeeding/breast milk feeding
in neonatal units. In Scotland change has already been taking place
throughout the last decade and there is a clear ‘shifting of the curve’ towards
breast milk usage and a breastfeeding culture in NNUs.
Increasingly, staff awareness and confidence about the benefits of breast milk
is palpable to the extent that the evidence presented here is largely
reminiscent of where we have come from and the breast milk journey travelled
so far. As we continue to challenge traditional practices it is clear that many
Scottish Neonatal Units are well underway, or indeed ahead of the curve
towards supporting breastfeeding/breast milk feeding.
Historically there has been a commonly held misperception that breast milk
can be easily substituted by formula without any serious or lasting harm to
sick and premature babies. Previously it was believed that these infants
cannot thrive on human breast milk alone and/or that their mothers are too
distressed to provide it. As marketing companies have normalised the use of
formula milk as a routine and preferred food, particularly in NNUs,
breastfeeding has been undermined. However, the health and development of
these most vulnerable infants needs to be protected by prolonged human
breast milk feeding.
Small changes have started to take place in response to the implementation
of the UNICEF Baby Friendly Maternity standards. Increased access to donor
4
breast milk in all neonatal units has resolved some of the issues of making
breast milk equally available to all babies who need it. In support of local
efforts, the new UNICEF Neonatal standards provide improved staff training
about the important issues of breast milk production, transitioning to
breastfeeding and creating an NNU culture that increasingly involves parents
in their babies’ care. In Scotland, additional support is offered by the
recommendations of the 2017 Maternity and Neonatal Services Review and
the review of the Maternal and Infant Nutrition Framework.
As society continues to view breastfeeding as problematic, many mothers
truly believe that they cannot breastfeed, or they have been so hurt by the
negative reactions of others that they stop doing so. Many women choose not
to breastfeed for reasonable and pragmatic reasons, but when their baby is
unwell, parents are often motivated to provide breast milk for their infant.
While it would be inappropriate to expect individual families to feel responsible
for what is in fact the systemic failure of our society to protect breastfeeding,
NNU staff have a unique opportunity to change the conversation by promoting
and protecting the use of breast milk/breastfeeding as part of caring for this
group of most vulnerable infants.
5
Introduction The positive health benefits of breastfeeding/breast milk feeding as part of
caring for premature, sick and vulnerable neonates is well documented in the
scientific literature. It provides the ‘best medicine’, offering protection against
hospital-acquired and other serious infections (such as necrotising
enterocolitis (NEC) and/or septicaemia). Breastfeeding/breast milk feeding
reduces mortality and provides the best nutritional support for such frail
babies.
Yet the difficulties experienced by pre-term mothers as they persevere with
providing breast milk for their baby are compounded by feelings of loss and
anxiety as staff may not have the knowledge, skills or time needed to support
parents and their NNU babies in a truly person-centred way because of time
pressures, established models of care and limited opportunities for training.
The aim of this paper is to summarise the best available evidence about
breastfeeding/breast milk feeding in neonatal units and to understand the
experiences of parents of NNU babies and the staff caring for them.
6
The relevance of the Health Care Quality Strategy ambitions to the experience of breastfeeding/breast milk feeding in neonatal units
The evidence in support of breastfeeding/breast milk feeding in NNUs was
considered with reference to the six Quality Ambitions of the Health Care
Quality Strategy for NHSScotland* that makes explicit connections between
patient priorities and the values of the people working for and within the NHS
in Scotland.
The Health Care Quality Strategy includes six (three key**) quality ambitions
that are outlined below:
1 Person-centred**: providing care that is responsive to individual
personal preferences, needs and values and assuring that patient
values guide all clinical decisions.
2 Safe**: avoiding injuries to patients from health care that is intended to
help them.
* See www.gov.scot/Resource/Doc/311667/0098354.pdf
7
3 Effective**: providing services based on scientific knowledge.
4 Efficient: avoiding waste, including waste of equipment, supplies,
ideas, and energy.
5 Equitable: providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, geographic location
or socioeconomic status.
6 Timely: reducing waits, and sometimes harmful delays, for both those
who receive care and those who give care.
The evidence included in the full evidence document* was considered through
the ‘lens’ of each of the six quality ambitions. Of particular interest was the
extent to which the dimension of person-centred care featured in the
experiences of both parents and NNU staff.
Although this key quality ambition specifically refers to the patient/family
experience, recent publications about staff experiences of supporting
breastfeeding/breast milk feeding in neonatal units are included below. These
provide insight into the needs of parents and the pertinent issues for staff
working in NNUs.
Identifying the evidence MEDLINE, Embase, Web of Science and Cochrane databases were searched
for systematic reviews published in English between November 2010 and
April 2014, including the following keywords: neonatal/intensive care, KMC,
low birth weight, premature, breastfeeding and breast milk. Additionally,
CINAHL and MIDIRS were searched during the same years, and included the
same key words, to identify qualitative papers that explored the infant feeding
experiences of parents and NNU staff.
* see: www.healthscotland.scot
8
In total eight systematic reviews and seventeen publications about qualitative
studies were identified. The findings from all these papers are summarised in
this document.*
The impact of premature delivery
Family perspectives
Mothers’ prevailing sense of being different was heightened because of
having a traumatic birth or Caesarean section. They were usually admitted to
postnatal wards that they shared with other mothers who had their baby
beside them.1
Being in hospital because of their own health issues, coupled with having their
infant in the NNU, was doubly disempowering for mothers as they lost
autonomy over their own behaviour and lost autonomy over beginning to
establish a close relationship with their new baby.1
The mother’s situation was compounded if they had pregnancy-related
complications (such as pre-eclampsia) and side effects of medication reduced
their understanding. This had a direct impact on their ability to follow early
instructions about expressing breast milk.2
Mothers who were too ill to be with their baby in the NNU reported distress as
they grieved for the normality of their pregnancy and the early motherhood
that they had anticipated.1
Separation from their baby provoked feelings of loneliness, especially at night
when mothers did not know whether their baby was awake and needing to be
fed.3 Often this physical separation, which created a sense of isolation and
‘unreality’, was only bridged by partners, who were considered to be
trustworthy links to the ‘other world of the baby’. However, this link was
* Full literature search details are available from Kate Woodman on request.
9
sometimes of little comfort as mothers, because of dashed expectations about
becoming a mother, continued to feel guilty, regretful and anxious.1
Mothers strongly believed in the importance of bonding with their baby at birth
through nurturing and caring for all of their baby’s needs. Being involved in
feeding and caring for their newborn was a crucial part of becoming familiar
with their baby’s responses, providing them with reassurance and reducing
their distress. However, mothers were unable to provide comfort in this way
because of their physical separation, or because they were discouraged from
doing so by NNU staff in view of their baby’s vulnerability. This heightened
mothers’ anxiety and fear in response to the fragility of their infant, which in
turn challenged their confidence in being able to nurture and care for their
baby.
Staff perspectives
As described by Taylor et al4, differences in nursing and midwifery practices
between the NNU and maternity units resulted in tensions between different
units and staff when working toward the implementation of the Baby Friendly
Hospital Initiative (BFHI):
‘The postnatal ward – they are very baby friendly up there. Very, very
baby friendly, and they probably see us [NICU*] as not so baby friendly,
but we have a different role to play than they have to play.’
Staff regarded the NICU as ‘a different world’ compared to the maternity unit
in which they had a unique role in caring for sick and/or premature infants who
required clinical treatment in a physical environment that was tailored to
provide such specialist care.
* Neonatal Intensive Care Unit.
10
The NNU infants needed more time to initiate and establish breastfeeding and
thus the rationale was provided for allowing certain practices that were not
supported within the application of the BFHI framework in the maternity unit:
‘We do use dummies down here and they have a place down in neonatal
intensive care for sucking and things.’
Staff considered the physical environment of the NNUs as impeding the
implementation of some of the BFHI steps. For example, rooming-in (Step 7)
was generally not available in the NICUs and was considered to be an
‘insurmountable challenge’ despite staff concern about mothers’ lack of
privacy and its impact upon breastfeeding.
The separated hospital spaces of the postnatal ward and NICU meant that
mothers were separated from their infants and thus they occupied ‘separate
worlds’, being responded to as separate entities rather than as a dyad. The
interdependence of their relationship was therefore difficult to maintain and
communication difficulties between staff across different wards or units were
compounded by a lack of clarity about who cared for the mother and who
cared for the infant, making it more difficult for staff to promote and help
maintain breastfeeding:
‘Now that mother wanted to breastfeed that baby, and we were boarding
the baby here, but it wasn’t going over [to high dependency] every feed
for a breastfeed.’
‘Hard work’ was required to overcome the difficulties encountered as staff
prepared for and started to implement the BFHI. These difficulties were
related to 1) a lack of funding/resources and 2) entrenched staff attitudes.
1. A lack of funding/resources for staffing and managing workloads made it
difficult to maintain the mother–infant interdependent relationship when
mothers and infants were separated. Therefore, staff felt unable to
appropriately support women and thus implement BFHI practices:
11
‘Sometimes you’ve got four babies, and the mother, you might have three
that are due and that mother comes in, she’s in tears, but unfortunately
the other babies have to be fed, and you can only give what you can give
at that time.’
It was equally ‘hard work’ trying to promote breastfeeding and the BFHI when
other essential resources to assist with breastfeeding, such as breast pumps,
recliner chairs, and privacy screens were in short supply.
2. The challenges of overcoming ‘entrenched attitudes and practices’ and
failure to provide adequate staff support for mothers who wanted to
breastfeed resulted in the giving of formula instead of promoting
breastfeeding.
Staff resistance was problematic for implementing the BFHI as practices that
had previously been considered as acceptable often led to formula being
given to infants as part of established practices:
‘I said we’ll start breastfeeding, and it sucked beautifully, but the nurse by
the bedside was so afraid. She insisted on giving [a hypoglycaemic baby]
a bottle.’
A lack of staff confidence in advocating in favour of breastfeeding as a first
option and in line with the BFHI resulted in nursing staff’s reliance on medical
decisions about infant feeding and the giving of formula:
‘You need to be able to do things, thinking yourself, without saying, “Oh
no, I can’t do that until tomorrow because the doctor won’t be doing
rounds until tomorrow, so I need to leave it.” That baby misses a whole
24 hours of feeding.’
12
‘Quick fixes of formula’ because a mother looked tired or to free up staff time
were given as supporting breastfeeding was considered as harder work and
more time-consuming for staff in the NICU:
‘You can give them the information to bottle feed really quick and then
with breastfeeding they have to spend the time with them.’
Nonetheless, staff believed that the BFHI could be achieved in NICUs despite
the limitations posed by its environment and structure. Some had led the way
by proactively bringing about change in response to their survey of mothers,
which had explored how staff could better support breastfeeding:
‘And I think we do skin-to-skin better with our early, preterm babies … So
in [our intensive care] bays one and two, kangaroo care and skin-to-skin
is done exceptionally well.’
Staff considered it positive that infants in the NICU often stayed for a long
time compared to infants in the maternity units. This long stay provided
greater opportunities for staff to educate mothers about infant feeding:
‘I find that, because our patients are longer term down here, there’s more
of an opportunity to speak to the mothers than there is working in
postnatal ward, when they’re in there for such a short period of time.’
Education was regarded as key to implementing the BFHI in NICUs and to
changing staff attitudes and behaviours and was vital for increasing the
confidence of nursing staff in promoting breastfeeding among both mothers
and medical personnel. The availability of lactation consultants* and staff
attendance at breastfeeding courses provided them with breastfeeding
knowledge and knowledge about the BFHI:
* This role is comparable to infant feeding advisors in Scotland.
13
‘I’ve been here for 20 years and I’ve only just done the lactation
consultant [course and exam], and I’m telling you now, not armed with all
this knowledge, I would have just said, give the formula.’
Positive ways to manage the implementation of the BFHI in the NICU context
included the encouragement of expressing breast milk, the involvement of
lactation consultants, and having clear policies/guidelines in place to directly
support the feeding regimes of infants with low blood sugars.
Although policies might minimise role confusion between staff in different
areas of the hospital, staff expressed caution that these needed to be clear
and appropriate, to prevent some staff rigidly applying a policy that was
sometimes detrimental to supporting breastfeeding.
Adapting to the neonatal unit environment
Family perspectives
As described by the Poppy Steering Group5, mothers and fathers found
periods of transitional care – the time of their baby’s birth, their arrival on the
neonatal unit, moving between different units and/or different levels of care
14
and leaving the unit to take the baby home – particularly stressful. At these
times parents valued:
• having consistent, clear information about the unit and caring for their
baby
• receiving emotional support
• getting practical guidance and encouragement about caring for and
feeding their baby, including ongoing support for breastfeeding.
Whenever possible parents needed to be prepared for their time on the
neonatal unit (either before their premature birth if expected, or afterwards if
there was little warning).
If their baby’s premature birth was unexpected, new fathers were often on
their own when they first visited the neonatal unit. This they found ‘shocking’.
Continuity of care was very important to parents, especially during crises, for
example when their baby was in transitional care and at the time of hospital
discharge when parents assumed total responsibility for their baby’s care for
the first time.
Immediately after their baby’s birth, parents wanted health professionals to
talk to them about opportunities to hold their premature baby; to help them to
provide KMC/skin-to-skin and to breastfeed. They appreciated being given
consistent information about how to care for their newborn and appreciated
being encouraged to express breast milk and to breastfeed. However, poor
communication, coupled with the availability of adequate privacy and practical
help while their baby was in the NNU, prevented parents from developing
realistic expectations about breastfeeding.
Parents reported their heightened uncertainty and fear at times when their
baby was transferred from one level of care to another. During such
transitions, parents appreciated health professionals’ continued emotional
support and support for breastfeeding/breast milk feeding.
15
Staff attitudes in relation to valuing and supporting breastfeeding/breast milk
feeding, being welcoming, supporting and working in partnership were vitally
important to parents’ experience of the NNU.5
A lack of privacy was a real barrier to breastfeeding/breast milk feeding. A
lack of homeliness (for example not having a place to leave some personal
belongings, and/or not having a chair next to their infant’s cot) and the
comings and goings of hospital staff inhibited mothers’ efforts to express
breast milk.6 This heightened their sense of being a visitor to the NNU where
strict feeding routines curtailed mothers’ efforts to responsively feed and care
for their baby.
The importance of breast milk and expressing
Family perspectives
Breastfeeding/breast milk feeding was highly valued by mothers as it was the
‘one thing that only the mother can do’ to contribute to protecting and
improving their baby’s health.
16
Mothers had faith in the healing properties of their breast milk and considered
it the most important thing that they could do for their infants. They equated it
to providing what their baby needed to gain and maintain health and to thrive.
‘I’m giving him life, medicine, food, and a part of me, all in a feeding every
two hours.’7
Mothers hoped that their breast milk would militate against the complications
associated with their baby’s prematurity, of which they were fully aware.
Expressing their breast milk also contributed to mothers’ healing. While they
felt guilty and blamed their bodies for delivering early (‘I couldn’t hold her in
my uterus long enough’7), mothers readily embraced ‘pumping’ as a chance to
maintain their baby’s health that had been interrupted by their infant’s
premature birth. Providing their breast milk also enabled mothers to renew the
‘connection’ that they felt with their infant during pregnancy.7
Mothers were comforted by the ritual of providing breast milk for their baby as
this enabled them to continue the unique biological connection that had begun
during pregnancy. Expressing breast milk helpfully provided some structure
and familiarity during a time of chaos and uncertainty. Some mothers were
reassured as ‘pumping’ offered them respite during the day when they could
bond with their infant and focus on them, even when they were separated
from each other.
Mothers felt rewarded knowing that their breast milk was helping their infants
to grow and were therefore motivated to continue so that their infant gained
weight. This in turn could make breast milk expression a rewarding
experience. However, despite believing in the healing properties of their
breast milk and its intrinsic value to their infant’s health, expressing breast
milk was profoundly disliked by mothers who found it degrading, time-
consuming and tiring.
‘It’s very degrading to sit on a breast pump for hours and hours a day
[and] have the horrible thing on your breast.’8
17
‘Kind of embarrassing and demeaning almost. Ya know, ’cause you feel
like a cow hooked up to a machine … Gotta do it though.’7
Expressing breast milk was hugely paradoxical. Mothers who had anticipated
carrying their infant to term became a ‘mother interrupted’. It was demanded
that she quickly adapt to both the foreign environment of the NNU and the
associated profound feelings of both separation and connection as the breast
pump represented both a link to and a wedge between the mother and her
baby.9
The emotional impact of expressing milk was particularly difficult if mothers
had previously breastfed older children, as the intimacy of breastfeeding was
replaced by the stark clinical/mechanical reality of pumping:
‘The pump don’t cry… it’s not demanding’ and ‘it’s easy to get distracted
when I don’t have her here at home to cry and let me know that she’s
hungry.’9
While mothers developed coping strategies to address practical issues, such
as having more than one set of breast pumps to speed up the process of
expressing and/or distracting themselves during the pumping process,
expressing breast milk demanded mothers’ unprecedented resilience.
Having adjusted to the NNU environment, mothers then had to respond to the
physical, practical and emotional challenges of continuing to provide breast
milk beyond their hospital stay, especially if they had returned to work.9
Dependence on others for lifts to and from the hospital posed problems for
mothers (with their home-expressed breast milk), who had to accommodate
partners, family members or friends who offered them lifts to the neonatal unit.
Alternatively, mothers who relied on public transport had to organise their
breast milk expression around the bus timetable.2
18
Being separated from their baby reduced the stimulation that mothers needed
to encourage their milk supply. Although returning to work provided distraction
for some working mothers, it also contributed to their ongoing exhaustion and
stress as they had to accommodate ‘pumping’ in work places that did not
provide time nor appropriate facilities.2
These ‘lived experiences’ highlight the importance of the recommendations
derived from earlier high-quality evidence that breastfeeding/breast milk
feeding in neonatal units is promoted by close, continuing skin-to-skin contact
between a mother and her infant, effective breast milk expression, peer
support in hospital and the community, and appropriate staff training.10
Mothers’ motivation to breastfeed/breast milk feed in the neonatal unit
Family perspectives
Mothers were motivated to breastfeed/provide breast milk because of their
understanding of the benefits of their own breast milk for their baby, which
encouraged them to develop coping strategies. Breastfeeding/breast milk
feeding was viewed by mothers as a way of compensating for their
19
‘interrupted pregnancy’11 and their baby’s vulnerability12 by offering their
unique nourishment to support their infant’s continued growth11. This
commitment allowed them to remain ‘connected’ to their baby, as they had
been in utero, and so enabled early bonding.11
Delays in starting to express breast milk and concern that their milk supply
would not meet the increasing demands of their growing infants constituted
barriers to breastfeeding/breast milk feeding that increased a mother’s anxiety
and sense of failure, as they wished for their baby’s more rapid weight
gain.11 12
Lack of privacy contributed to the stress of less confident mothers who felt
‘exposed’ and vulnerable because of their sense of being compared to others,
as expressed breast milk was left on open racks. This gave rise to feelings of
hopelessness and failure. Similarly, mothers who lacked confidence in their
milk supply became ‘addicted’ to weighing scales, perceiving their infant’s
weight gain ‘as a kind of race’ in which they competed with other mothers.3
The support of nursing staff was pivotal as mothers were keen to learn
feeding techniques and to understand their baby’s cues and behaviours.11
Consistently positive reinforcement by staff, who confidently provided
accurate information and guidance about breastfeeding and strategies to
increase a mother’s milk supply, supported mothers’ early feeding efforts.
Conversely, a lack of expert or conflicting advice and inconsistent information
given by health professionals and/or staff perceptions about mothers’ and
fathers’ needs, which were different from those of parents, constituted barriers
to breastfeeding/breast milk feeding in the neonatal unit.12
20
Staff perspectives
As described by McInnes et al13, the decision to start oral feeding* was based
on staff assessment of a baby’s readiness to do so. Feeding decisions were
influenced by nursing staff’s experience, their sense of ‘knowing the baby’ and
competing demands in the NNU. Parents were not involved in decisions about
when to start oral feeds, as this nursing/clinical decision was communicated
later to them.
The transition to oral feeding was inconsistent as decisions differed according
to staff experience and beliefs, the established practices of the NNU, parents’
expectations and the physical constraints within the NNU. Such
inconsistencies resulted in infants (and their parents) experiencing a range of
practices and management styles from different staff members.
The timing and frequency of feeding also varied depending on whether the
NNU adopted a largely structured or baby-led approach and, while some staff
would ‘save’ oral feeding for when parents anticipated being in the NNU, this
approach was inconsistently adopted. On the contrary, some staff
discouraged parents from being involved in their baby’s early or first feeds
because of parents’ inexperience.
During the transition to oral feeding, an infant’s daily milk requirements were
prescribed according to the NNU protocol, with the total volume divided into
six or eight equal amounts, depending on whether the infant was being fed
3- or 4-hourly. At each feed the baby was encouraged to have the prescribed
volume and at the end of the feed any remaining milk would be given via a
nasogastric tube as a ‘top-up’. However, the information used to calculate
feed volumes was unclear and thus staff were concerned about the frequency
and volume of feeds, as some infants were overfed, sometimes to the point of
being sick.
* This could include breast, cup, spoon or bottle feeding.
21
The continuous increase in prescribed milk volumes was an added pressure
for mothers who were trying to express their breast milk in an already difficult
situation. Additionally, supplementing breast milk with (increasingly) large
quantities of formula was potentially demoralising for mothers, particularly if
they had an ‘inadequate’ breast milk supply:
‘That can be discouraging to some mums when they think the baby’s only
getting a quarter of her milk and three quarters of something else.’
Because measuring breast milk intake was impossible, an infant’s intake and
need for a ‘top-up’ was judged according to whether the staff or the mother
thought that the baby had had a ‘good’ breastfeed. This judgement was based
on assessing breastfeeding techniques, mother’s breast assessment and/or
counting how often the infant was being breastfed. However, staff were
unable to clearly or consistently account for how they would work out the
volume of a ‘top-up’ if it was deemed necessary.
Weight gain was considered as an important indicator of successful
breastfeeding, although test weighing was unacceptable to staff. Despite
nurses favouring a more holistic assessment of the infant’s overall wellbeing,
growth and particularly weight gain were overarching indicators of successful
feeding.
Mothers who wished to breastfeed needed to decide how their infant should
be fed when they were not in the NNU. This decision was respected and
adhered to. Although cup feeding was advised in infant feeding policies, the
actual practice varied within and between NNUs. As the majority of staff
disliked cup feeding because it was considered to have no benefit, it was
unclear as to how mothers were supported to make an informed choice. While
staff felt that mothers were given appropriate information about the use of
bottles and cups, others suggested that mothers would likely be encouraged
to agree that her infant could be bottle-fed in her absence.
22
Many contextual factors that hindered or helped breastfeeding/breast milk
feeding in neonatal units were identified in the evidence. These are presented
below.
Parent-related issues
Identified barriers included:
• Physical separation from their infants12
• A lack of role models12
• Distance from home12
• Exclusion of fathers and other family members, which limited their
emotional support12
• Lack of privacy12
• Competing time demands12 including the need to keep family and
friends updated about their baby’s progress2, work demands and
caring for older children8
• Being of low socioeconomic status12
• The particular circumstances inherent in multiple births14
• Previous breastfeeding experiences14
• Social stress14
• Tiredness8
23
Identified enablers included:
• Parents’ decisions/mutual commitment to breastfeeding/providing
breast milk for their infant12
• Having good social support12
• Having hope that their breast milk supply would be easier once home12
• The use of social media to keep others updated about their baby’s
progress that widened the opportunity for ongoing social support2
Baby-related issues
Identified barriers included:
• Complications associated with prematurity14
• Specific ‘trigger events’, indicating the start of breastfeeding difficulties,
for example circumcision14
NNU structural/staff-related issues
Identified barriers included:
• NNU structured feeding routines that discouraged parents from being
available for responsive feeding8 12 13 14
• Staff values related to their coping with uncertainty that were
counterintuitive to the mother–baby process of breastfeeding15
• Staff emotional disengagement from parents as they focused on
closely monitoring the baby15
• The perceived ‘intrusion’ of staff as they supervised parents8
• Staff insensitivity to parents’ time and other stress, particularly when
mothers needed to be at the NNU at specified times to feed their
baby8 13
• Inconsistent and inaccurate information about infant feeding given by
staff8 13 17
24
• Staff reliance on NNU peer supporters to emotionally care for parents17
Identified enablers included:
• The availability, accessibility, perceived interest of and the provision of
accurate information by paediatricians, lactation consultants, nurses
and obstetricians12 14
• Gradual, well-led organisational change and staff development that is
sensitive to existing values and ways of practice15 17
Coping strategies in response to breastfeeding/breast milk feeding in the neonatal unit
Family perspectives
Mothers demonstrated resilience in response to their fears and worries about
their frail underdeveloped baby. This was coupled with their sense of shock
and trauma at the circumstances surrounding their infant’s birth. In response
mothers developed a repertoire of coping strategies to help them manage the
tension between the value they placed on breastfeeding/breast milk feeding
and the mental and physical stamina that it demanded. Mothers, despite
being rebuffed by their unresponsive baby, ‘weighed worth against uncertain
work’ by remaining committed to breastfeeding, perceiving it as being central
to their nurturing maternal role, and/or valuing the health benefits for
themselves and its convenience.
Mothers engaged in trial and error guess work as they tried to identify and
overcome their infant’s feeding problems. They would try to hold out hope,
seeking support from peers and professionals to encourage their efforts to
sustain breastfeeding/breast milk feeding.14
25
Swanson et al1 describe how mothers strived to develop a sense of self-
efficacy that was derived from four experiences:
1. Mastery or skill – especially in response to feeding difficulties or challenges.
This sense of mastery was also influenced by mothers’ knowledge, attitudes,
beliefs, experience and interactions with others that could be supportive or
unhelpful.
2. Modelling (copying others). Mothers drew upon staff support and
encouragement as they were shown how to tube feed and how to express
breast milk. However, as few mothers actually breastfed in the NNU, there
were few successful breastfeeding role models for mothers to emulate.
Support from partners was also influential, especially when they helped with
tube feeding. This could increase a mother’s knowledge and self-efficacy as
she modelled her partner’s behaviour.
3. Emotional and practical support from health professionals. This was an
important ‘conduit’ for developing self-efficacy, improving autonomy and a
sense of control in hospital and/or overcoming feelings of ambivalence about
breastfeeding. Some staff persuaded women to continue breastfeeding when
they were considering stopping. On the other hand, inconsistent advice was
confusing and reduced mothers’ self-efficacy.
The opportunity for mothers to gain practical support from their wider family
was denied as they were excluded from getting to know and care for their new
family member while the baby remained in the NNU. This reduced mother’s
self-efficacy, causing distress and anxiety.
4. Dealing with physiological and emotional states. Mothers described how
expressing their breast milk enabled them to re-establish the discontinued
relationship with their infant through their breast milk. This was described by
the researchers as a special or connecting substance that came from their
body:
26
‘I feel really connected to her and that I’m doing something for her, not
just putting something down a tube or changing a nappy, that I’m really
providing for her.’
Providing breast milk symbolised mothers’ unique maternal role in the face of
disempowerment as it enabled them to redress feelings of failure or guilt
following premature birth.
When they were able to provide breast milk for their baby, mothers described
positive emotions such as love, pride, contentment and pleasure that
contributed to their sense of self-efficacy.
Staff perspectives
As described by Cricco-Lizza15, nurses were highly motivated to maximise the
potential of all NICU babies in the midst of uncertainty. Their work allowed
them to ‘do something that is pretty valuable and important’, in keeping with
the unit’s goal which was to help NICU babies to ‘go home and be the best
that they can be within the family’. Yet as infants with acute care needs were
27
the ‘top priority’ for nursing staff, the uncertainty of these infants’ outcomes
and the unpredictability of their complex care posed significant challenges to
nurses, many of whom disliked uncertainty and thus kept a steadfast vigil that
provided them with a sense of consistency.
‘Relying on the sisterhood of NICU nurses to deal with uncertainty’ was part of
the staff repertoire of coping skills as nurses helped each other until specific
crises were resolved and/or acute problems solved. They would ‘spring into
action around the bedside’ to care for a new admission, fresh post-operative
case, or a baby in crisis, with each assuming a specific role in their efforts to
stabilise the baby, support the family and maximise the chances for a healthy
outcome.
A general spirit of camaraderie and a reciprocal willingness to help out was
highly valued and prevailed as less experienced nurses were guided by senior
staff during sudden emergencies:
‘I feel very close to the girls … we do so many things in the unit;
sometimes it takes two to divide up and conquer it.’
‘When it is your turn, you don't want to sink … we all back each other up
here, help each other out.’
Nurses’ proactive confrontation of the uncertainty of their care was three-fold
as they placed a high value on the following:
1. Taking tight control of their actions. This empowered nurses to
proactively manage their daily nursing care so that they could ‘make order’ of
their care of their infant patients, instead of becoming ‘overwhelmed’ by
uncertainty. Nurses talked freely about taking control by being task focused,
strictly organised, and meticulous in their goal setting. In addition, they were
vigilant, and attended to detail in their everyday work. Nurses valued ‘tight
control’ which they associated with better outcomes for the infants. Their
28
success in maximising fragile babies' outcomes was related to their personal
and deliberate nursing care efforts:
‘Day to day, we do so much for them, and if you have a sick kid, you
know you pretty much might have just saved her life.’
Because of the ‘smaller safety margin’ involved when caring for fragile infants
compared with sick children or adults, nurses took very ‘close control’ over all
of the details of care:
‘Just tighten up things and make the gears work better. I like efficiency. I
like productivity. I'm very systematic; that's the way that I work. When I
see something that's not efficient it does tug at me. Sometimes little
things bug me just a little bit more. It's like if something had just a little bit
more attention paid to it; a little bit more detail about it, a little more
consideration, then things would have been a little bit smoother.’
Their ‘attention to detail and constant monitoring’ allowed nurses to pick up on
early changes in the health status of the babies. Nursing staff exhibited ‘razor-
sharp sensitivity’ to sudden changes and in many situations their sense of
focus that saved lives was appreciated by both families and other NICU staff
alike. Nurses were delighted when recovered babies and their parents came
back to visit the NICU and when parents specifically asked to see the nurses
who had cared for them:
‘Knowing that there are good outcomes like that, I think is why we all
stay.’
When describing infants with multisystem problems, nurses were acutely
aware of the care that was needed to save such young lives:
‘We work as a collective force to make babies that didn't live, live ... I'm in
a field that we have life and death … and I'm thinking how to do it better,
how to make them better. That is very hard.’
29
Yet, despite the importance that they placed on controlling care to maximise
the health outcomes of babies, nurses also emphasised that uncertainty could
not always be overcome:
‘I think organisation is relatively key; it's very important, but you know you
can't always be prepared for things that might crop up.’
And thus nurses valued tight control to help decrease their discomfort in the
face of uncertainty.
The control that nurses routinely used to cope with uncertainty in the NICU
was not easy to integrate with breastfeeding promotion, with some nurses
expressing their anxiety about vulnerable babies taking their first breastfeed:
‘Yeah, the first time that they've ever fed, it's a little intimidating just
handing the kid to the mom … Unless it's an easy, stable baby, we don't
do that very often … If you're feeding the baby yourself you have much
more control than if you just hand the baby over to the mom if she's
nursing.’
And as most nurses acknowledged that managing the transition to
breastfeeding in the NICU was not as successful as breast milk feeding,
nurses felt this transition needed to be improved.
2. Reliance on technology. This was regarded as a valuable tool that was
deeply embedded within all aspects of NICU care and helped to save lives.
Technology enabled nurses to take over an infant’s vital life functions and to
provide continuously recorded data about any slight changes in an infant’s
condition. Nurses liked the challenge of caring for the sickest babies with the
most modern equipment, and they highly valued the use of technology to
guide their everyday care:
30
‘I like the technology ... I'm learning new skills constantly. I'm always
working with the latest things that are out there ... I need to keep up my
skills.’
Such technical skills improved nurses’ ability to respond to the health threats
that faced vulnerable infants and, in so doing, nurses could proactively
decrease uncertainty and improve the outcomes for the infants in their care.
Nurses who had worked in the unit for many years reflected upon how
technical demands had replaced traditional nursing care:
‘We had more time for the family … We are doing a lot more for that
patient. There is a lot more testing, a lot more procedures. The care is
just more intense.’
Thus, in the course of handover reports, nurses focused on a multitude of
technical details about medications, monitor readings, procedures, and
physiological parameters that appeared to be of priority:
‘Sometimes the social [information] is usually the last thing that we cover
when we're giving a report unless there is something big going on.’
Therefore it could be appreciated that as much as nurses relied on technology
to counteract uncertainty, modern technology also made demands on their
time and priorities in the NICU.
While enteral feeds, with specialised formulas that were often prescribed by
physicians, offered mechanical support to infants who were unable to feed
directly by mouth, actual breastfeeding in the NICU was considered to be
highly technical and more labour-intensive. Importantly, nurses viewed breast
milk as a measured product, as opposed to being vital to building the
mother–baby relationship.
Interestingly, breastfeeding support included assessment of the mother's
needs, education, placement of privacy screens, positioning of mother and
31
baby, and emphasis on measurement with pre and post weights with
specialised scales. Nurses acknowledged the difficulties with this process:
‘If it's in a bottle it's much easier to know, especially in the beginning,
when the moms don't have a lot of milk. It's just kind of we're very number
based.’
3. Maximum efficiency in the use of time. Nurses continually grappled with
uncertainty and sudden crises associated with fragile infants, valuing time as
‘a precious commodity’. Often they referred to getting routine care ‘done’ as
efficiently and quickly as possible so that they could be ready for the
unexpected. However, in a ‘hectic’ unit this resulted in stress:
‘It's hard to keep up with everything and make sure you're doing
everything right, and a lot of things are very time consuming, when you
are trying to take care of the baby, and then you're trying to think of all
these other little details.’
Nurses dealt with minute-by-minute changes in care, and their energy and
efforts were focused on immediate concerns. Thus, they had a limited
appreciation of the wider mother–infant issues beyond that of the specialised
acute treatment in the NICU. However, nurses who were mothers and
particularly those who had had NICU babies themselves had a greater
understanding of the long-term mother–child health concerns.
The nurses’ practice values in the culture of the NICU prioritised time
efficiency to control uncertainty. Several referred to the amount of time that it
took to counsel women about breastfeeding and to support them. A few
nurses believed that both breastfeeding and formula were nutritious options.
However, breastfeeding was seen as more time-consuming and difficult when
nurses were primarily focused on weight gain and hospital discharge.
32
Peer support in the neonatal unit
Family perspectives
Rossman et al16 describe how the sharing of experiences and offer of
emotional support by those who had ‘walked in their shoes’ gave hope and
relief and reduced mothers’ sense of isolation.
As peers essentially ‘mothered the mother’, they provided personalised,
nurturing and non-judgemental attention to new mothers who were starting to
provide breast milk and cope with having an infant in the NNU.
Mothers were inspired by the peer supporters’ stories and recounting of their
experiences. These gave mothers the strength to continue with expressing
their breast milk/breastfeeding.
Peer supporters’ ‘connection’ helped mothers to appraise their situation in
favour of persevering with breast milk feeding and developing coping
strategies to help them incorporate pumping into their lifestyle. Peer
supporters helped mothers to ‘normalise’ their experiences by providing them
with ‘accessible’ information related to the importance of breast milk and the
mechanics of pumping along with offering practical support in relation to
accessing equipment.
Mothers felt cared for by the peer supporter, referring to them as family or
friends. Some who benefited from such care expressed their wish to become
role models for others in similar situations, either by later becoming a peer
supporter themselves or by simply relating their story and sharing their
experiences with other mothers in the NNU.
Staff perspectives
As described by Rossman et al17, NICU staff (including nurses,
neonatologists, lactation consultants, and dieticians) felt that breastfeeding
33
peer counsellors (BPCs) enhanced the care of infants and their mothers in the
NICU. Staff considered the BPCs as assets who made the work of NNU staff
easier as they provided unique support to parents because of their shared
experience.
Despite their clinical experiences and/or education and experience in helping
mothers of healthy term infants with establishing breastfeeding, NICU nurses
lacked the in-depth lactation expertise that was needed by expressing
mothers to support infant feeding. They therefore described the breastfeeding
peer counsellors on whom they depended as a ‘blessing’ because they
‘lightened the nurses’ load’.
As nurses’ priority was the health and safety of the infants in their care, often
they did not have the time to help mothers with expressing breast milk or
breastfeeding and so they valued the BPC as an additional resource and
considered their involvement as being in the best interests of the mothers on
whom they were focused and to whom they provided empathic emotional
support.
The BPCs’ lactation expertise was highly valued and nurses took advantage
of opportunities to learn from them. This appreciation was shared by other
NICU staff members.
Because the BPCs shared the evidence about breast milk and lactation with
the infant’s family, all staff considered the BPC programme as compatible with
the values of family-centred care that was offered in the NICU. Nurses
commented on the BPCs’ ability to include and support other family members,
teaching partners, grandmothers, mothers or sisters how to be of real help to
parents. In so doing, the BPCs reached out to and involved other family
members in supporting the baby in the NICU. Indeed, the majority of other
staff credited the BPCs with the 95% rate of human milk feeding in the NICU.
The BPCs maintained a visible presence among NICU staff and parents alike
as they passed through the unit and spent time with mothers. Staff alluded to
34
the fact that because the BPCs had ‘all been through this kind of roller coaster
ride’ with their own infants, their shared experience helped them ‘bond’ with
new mothers who then asked for help from the BPC rather than from nursing
staff. Once again, the high rate of breast milk feeds was attributed to the
BPCs’ obvious presence:
‘As high as 95% of all of our kids … are receiving breast milk and it’s my
perception that it’s the peer counsellors that should be given a significant
degree of credit for that. That’s just a remarkable finding in an urban
academic centre. Nobody comes close. My understanding is that it’s kind
of like 50% or 60% in the rest of the world.’
BPCs were considered as being both accessible and consistently responsive.
Nurses routinely called upon them for support, either because mothers had
asked for them or because the nurse needed help from the BPC to offer
emotional support to a family whose baby was in the NICU.
The wider health care staff considered the BPC as integral to the team who
were supporting the NICU culture in which mothers’ milk was regarded as
medicine to reduce the risk of complications that were associated with
prematurity.
A multidisciplinary approach to breastfeeding/breast milk feeding support had
been embraced in the NICU described by Rossman et al17, as the BPC
collaborated/consulted with the range of NICU specialties about the best use
of human milk to optimise infant outcomes:
‘I think we work as a team of people who all have different things to do
…The peer counsellors do breastfeeding things and provide that
one-of-a-kind perspective that helps families be successful.’
The value of their integrated role was also acknowledged and respected by
nursing staff, who preferred to page the BPC rather than risk giving inaccurate
information or advice to mothers:
35
‘I’m not threatened by them (peer counsellors). They’re not taking my role
over. They’re just part of the team.’
‘We really have a great respect for each other since we have the same
goal of helping the families.’
All health care providers noted that the BPCs provided mothers and families
with consistent and accurate messages about the value of human milk, with
neonatologists praising the breastfeeding peer counsellors for maintaining
mothers’ enthusiasm for long-term breast milk expressing during their NICU
stay.
Staff acknowledged the valuable contribution made by the champion of the
BPC programme, the nurse director of the clinical research and lactation
programme who was described as a visionary and a transformational leader.
Seamlessly, the first BPCs had been introduced slowly, ‘like a ripple under the
water’, with minimal disruption to prevailing NICU practices and therefore
within a short space of time they were perceived as helpful.
In response to the contribution made by the breastfeeding peer supporters,
the majority of health care and nursing staff acknowledged that the BPCs
were able to truly identify with and understand the emotional turmoil of
mothers because of their own experience of having had an infant in the same
NICU. Thus, the BPCs conveyed compassion for mothers, helping them to
cope:
‘They truly are that bridge where people can say, “I have had the same
experience as you.” I think that’s priceless. It just allows parents to get
through some really tough times.’
36
The need to get home
Family perspectives
Getting home was seen as a step toward re-establishing ‘life’s normality’, yet
mothers were often ambivalent, experiencing conflict between wanting to take
their baby home where they would be ‘in control’, and lacking confidence or
worrying about being able to care for their baby without the support of NNU
staff.1
Mothers needed to feel prepared for going home and such readiness was
associated with feelings of having developed a close loving relationship with
their infant as their sole care of their baby increased. They felt that they
should know their baby better than NNU staff and that they should ‘feel like
the baby’s mother’ before going home. Such empowerment necessitated the
transfer of responsibility and autonomy from NNU staff to the mother/parents.1
Yet some mothers described NNU nurses as inappropriately ‘owning’ their
baby:
‘She doesn’t feel like she belongs to you. You feel like she belongs to
them and you’re just visiting.’ This felt: ‘Really awkward as a mother
because [it’s] your son and you don’t know if you can hold him or not.’8
37
In addition, parents perceived staff supervision as interrupting and/or intruding
on normal parent–infant bonding:
‘We still weren’t sure whether you were allowed to pick her up … and the
inability to touch them and sit with them and things like that … You can’t
cuddle them.’ It was ‘very stressful to walk out and leave them in the
nursery.’8
As hospital protocols often stated that babies had to be successfully feeding
(independent of tube feeding, able to suck from the bottle or breast and
gaining weight), this stipulation presented a particular challenge for parents as
breastfeeding and taking their baby home became competing goals.
Moreover, as establishing successful breastfeeding was more difficult among
preterm babies this resulted in longer hospital stays. Therefore, when faced
with such a dilemma, mothers were pragmatic, deciding to use bottles to feed
breast milk or formula to their babies, rather than risk not getting home.1 8
38
The cost-effectiveness of providing breast milk for preterm infants Breast milk from the biological mother reduces the burden of disease and
associated costs of caring for an infant in the neonatal unit.
Recent economic analyses18 predict that by increasing the current rate of
breastfeeding/breast milk feeding at discharge from neonatal units from 35%
to 50%, approximately £2.3 million each year could potentially be saved that
is currently spent treating necrotising enterocolitis (NEC) in infants in neonatal
units. A further increase of breastfeeding to 75% could save up to £6 million
per year. If breastfeeding rates at hospital discharge increased to 100%, the
cost savings could increase to £10 million per year.
If all babies were breastfed/fed breast milk at discharge from neonatal units,
the number of cases of NEC would fall from 798 to 212 per annum, which is
the rate that is currently achieved in some neonatal units in Europe and the
United States. This analysis does not include the impact of lives lost to NEC,
which is considerable.18
Because the cost of acquiring breast milk is directly related to the mother’s
expressed milk volume, NNU staff need to prioritise the prevention, diagnosis
and management of problems related to expressing breast milk.19 This
concurs with the findings from a UK-based study that indicated that enhanced
staff contact may be cost-effective in an NHS context.20
While the current economic environment, with its emphasis on cost
containment, provides an impetus for immediate and thorough investigation of
strategies to improve the health of VLBW* infants in the NNU, in addition, the
health costs to the families of NNU infants cannot be underestimated and thus
warrants further investigation.21
* Very low birth weight.
39
A second dimension of cost ‘efficiency’ is that related to the commitment of
NNU staff to encourage breastfeeding/breast milk feeding. Such ‘efficiency’
depends upon NNU nurses being involved in:
• the development of organisational and human resources to support
breastfeeding
• the provision of infant feeding/breastfeeding education
• multidisciplinary representation for breastfeeding on hospital
committees and projects
• the limiting of formula marketing practices in the NNU to avoid
inconsistent messages about infant feeding
• auditing of breastfeeding and breast milk feeding rates to guide
breastfeeding/breast milk promotion efforts.22
40
Providing donor human milk in the neonatal unit The purpose of human milk banking is to provide a human milk supply for
preterm infants if a mother’s own breast milk is not available and/or in short
supply.
Recent high quality evidence emphasises that making donor human milk
(DHM) available in neonatal units does not reduce breastfeeding rates at the
time of hospital discharge and decreases the use of formula in the first four
weeks of life.
Feeding preterm infants with DHM compared to formula is associated with a
decreased risk of NEC.23
DHM may improve feeding tolerance, protect against bronchopulmonary
dysplasia, protect against the development of allergies in preterm infants (who
are at high risk for allergy) and have a beneficial impact on later
cardiovascular risk factors.24*
UNICEF endorses the giving of donor human milk as a viable option when
breastfeeding is not possible (see: www.unicef.org.uk/wp-
content/uploads/sites/2/2013/09/baby_friendly_evidence_rationale.pdf).
* Although donor human milk has been shown to have no significant long-term benefit to neurodevelopment24 it may be that such improvements can only be identified at a later age and thus this evidence remains lacking.
41
The benefits of kangaroo mother care in the neonatal unit Kangaroo mother care (KMC) essentially involves continuous skin-to-skin
contact (SSC) between a mother and her newborn. It facilitates frequent and
exclusive or nearly exclusive breastfeeding, and early discharge from hospital
is an effective and safe alternative to the conventional neonatal care of low
birth weight infants, particularly in resource-limited countries.
Compared with conventional neonatal care, KMC at hospital discharge, or
40–41 weeks' postmenstrual age or at latest follow-up, has been found to
reduce:
• mortality
• severe infection/sepsis
• nosocomial infection/sepsis
• hypothermia
• severe illness
• lower respiratory tract disease.
There were no benefits to either neurodevelopmental or neurosensory
outcomes for babies (at 12 months’ corrected age).
KMC resulted in an increase in:
• Body weight, length and head circumference
• Breastfeeding at hospital discharge (and at 1 to 3 months’ follow-up)
• Maternal satisfaction with the method of infant care
• Some measures of maternal–infant attachment
• Some measures of the family home environment.25*
* The reader should note that the evidence presented here is from the review that was updated in 2016 by the same authors (that was previously published in 2014).
42
These findings reflect earlier high quality evidence that indicated that daily
kangaroo skin-to-skin contact with mothers (ranging from 10 minutes to
2 hours) for very low birth weight infants (under 1,500g) increased the
continuation of any breastfeeding at the time of hospital discharge and up to
one month afterwards.26 In addition, the routine use of KMC for all babies
under 2000g has been recommended as soon as they are stable.
Up to half a million neonatal deaths due to preterm birth complications could
be prevented each year if this intervention were implemented at scale.27
43
Relevant Scottish and international policy documents
Breast milk/breastfeeding in neonatal units is supported by several policy
drivers in Scotland and is the core business of the NHS as highlighted in the
following documents:
• The best start: a five-year forward plan for maternity and neonatal care
in Scotland (www.gov.scot/Resource/0051/00513175.pdf)
• A route map to the 2020 vision for Health and Social Care (Scottish
Government, 2013: www.gov.scot/Resource/0042/00423188.pdf)
• Improving Maternal and Infant Nutrition: A Framework for Action
(Scottish Government, 2011:
www.gov.scot/resource/doc/337658/0110855.pdf)
• The Health Care Quality Strategy for NHSScotland (Scottish
Government, 2010: www.gov.scot/resource/doc/311667/0098354.pdf)
Other key documents include the following:
• Children and Young People’s (Scotland) Act 2014:
www.legislation.gov.uk/asp/2014/8/contents/enacted
44
• Guide to the Baby Friendly Initiative standards (UNICEF, December
2012: www.unicef.org.uk/wp-
content/uploads/sites/2/2014/02/Baby_Friendly_guidance_2012.pdf
• Getting it right for every child (GIRFEC), 2008:
www.gov.scot/Resource/0049/00498272.pdf
• The United Nations Convention on the Rights of the Child:
www.unicef.org.uk/UNICEFs-Work/UN-Convention
Particularly relevant is Article 24 of the UNCRC that refers to health and
health services:
‘Children have the right to good quality health care – the best health care
possible – to safe drinking water, nutritious food, a clean and safe
environment, and information to help them stay healthy. Rich countries
should help poorer countries achieve this.’
Other documents that provide the context for this briefing are described in the
full evidence paper that underpins this briefing that will soon be available on
the NHS Health Scotland website.
45
Acknowledgements NHS Health Scotland wishes to acknowledge the support of the following
people:
• Professor Mary Renfrew, Director of the Scottish Improvement Science
Collaborating Centre (SISCC), University of Dundee, who peer
reviewed the evidence paper that supports this briefing.
• Linda Wolfson, National Maternal & Infant Nutrition Coordinator,
Scottish Government, for her ongoing support and helpful contribution
to the drafting of this evidence summary.
• Members of the Scottish Infant Advisors Network (SIFAN), for their
constant support and advice throughout this project.
• Members of the Neonatal Breast (milk) Feeding Advisory Group, for
their guidance throughout the initial stages of this project.
• Gillian Clark, SISCC Administrator, for her publication support.
• Best Beginnings and Queen Elizabeth University Hospital for
generously providing the photos in this document.
46
References 1 Swanson V, Nicol H, McInnes R et al. Developing maternal self-efficacy
for feeding preterm babies in the neonatal unit. Qualitative Health
Research 2012, 22(10):1369–82.
www.ncbi.nlm.nih.gov/pubmed/22829487
2 Sisk P, Quandt S, Parson N and Tucker J. Breast milk expression and
maintenance in mothers of very low birth weight infants: supports and
barriers. Journal of Human Lactation 2010, 26(4):368–375.
http://journals.sagepub.com/doi/abs/10.1177/0890334410371211
3 Björk M, Thelin A, Peterson A and Hammarlund K. A journey filled with
emotions – mothers’ experiences of breastfeeding their preterm infant
in a Swedish neonatal ward. Breastfeeding Review 2012, 20(1):25–31.
www.ncbi.nlm.nih.gov/pubmed/22724310
4 Taylor C, Gribble K, Sheehan A et al. Staff perceptions and
experiences of implementing the baby friendly initiative in neonatal
intensive care units in Australia. JOGNN 2011, 40(1):25–34.
http://onlinelibrary.wiley.com/doi/10.1111/j.1552-
6909.2010.01204.x/abstract
5 Poppy Steering Group. Family-centred care in neonatal units: A
summary of research results and recommendations from the Poppy
Steering Group Project. London: NCT; 2009.
www.assembly.wales/NAfW%20Documents/hwlg_3_-nnc001b-nct-
poppy_report_2009.pdf%20-%2022032010/hwlg_3_-nnc001b-nct-
poppy_report_2009-English.pdf
6 Flacking R and Dykes F. ‘Being in a womb’ or ‘playing musical chairs’:
the impact of place and space on infant feeding in NICUs. BMC
Pregnancy and Childbirth 2013, 13:179.
47
http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471
-2393-13-179
7 Rossman B, Kratovil AL, Greene MM et al. ‘I have faith in my milk’: the
meaning of milk for mothers of very low birth weight infants hospitalized
in the neonatal intensive care unit. Journal of Human Lactation 2013,
29(3):359–365.
http://journals.sagepub.com/doi/abs/10.1177/0890334413484552
8 Swift MC and Scholten I. Not feeding, not coming home: parental
experiences of infant feeding difficulties and family relationships in a
neonatal unit. Journal of Clinical Nursing 2009, 19:249–258.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-
2702.2009.02822.x/abstract
9 Hurst N, Engebretson J and Mahoney JS. Providing mother's own milk
in the context of the NICU: a paradoxical experience. Journal of Human
Lactation 2013, August, 29(3):366–373.
http://journals.sagepub.com/doi/abs/10.1177/0890334413485640
10 Renfrew MJ, Craig D, Dyson L et al. Breastfeeding promotion for
infants in neonatal units: a systematic review and economic analysis.
Health Technology Assessment 2009, 13(40):1–146.
www.ncbi.nlm.nih.gov/pubmed/19728934
11 Boucher CA et al. Mothers’ breastfeeding experiences in the NICU.
Neonatal Network – Journal of Neonatal Nursing 2011, 30(1):21–28.
www.unmc.edu/nursing/docs/BF_Experiences_NICU2011-
14CE030.pdf
12 Alves E, Rodrigues C, Fraga S et al. Parents’ views on factors that help
or hinder breast milk supply in neonatal care units: systematic review.
Archives of Disease in Childhood – Fetal and Neonatal Edition 2013,
98: F511–F517. http://fn.bmj.com/content/98/6/F511
48
13 McInnes RJ, Shepherd AJ, Cheyne H and Niven C. Infant feeding in
the neonatal unit. Maternal and Child Nutrition 2010, 6:306–317.
http://onlinelibrary.wiley.com/doi/10.1111/j.1740-8709.2009.00210.x/full
14 Demirci JR, Happ M, Bogen DL et al. Weighing worth against uncertain
work: the interplay of exhaustion, ambiguity, hope and disappointment
in mothers breastfeeding late preterm infants. Maternal and Child
Nutrition 2012, 11(1):59–72. www.ncbi.nlm.nih.gov/pubmed/23020593
15 Cricco-Lizza R. Everyday nursing practice values in the NICU and their
reflection on breastfeeding promotion. Qualitative Health Research
2011, 21(3):399–409.
http://journals.sagepub.com/doi/abs/10.1177/1049732310379239
16 Rossman B, Engstrom JL, Meier PP et al. ‘They've walked in my
shoes’: mothers of very low birth weight infants and their experiences
with breastfeeding peer counselors in the neonatal intensive care unit.
Journal of Human Lactation 2010, 27(1):14–24.
http://journals.sagepub.com/doi/abs/10.1177/0890334410390046
17 Rossman B, Engstrom JL and Meier PP. Healthcare providers’
perceptions of breastfeeding peer counselors in the neonatal intensive
care unit. Research in Nursing & Health 2012, 35(5):460–474.
www.ncbi.nlm.nih.gov/pmc/articles/PMC3442151/pdf/nihms391920.pdf
18 Renfrew MJ, Pokhrel S, Quigley M et al. Preventing disease and saving
resources: the potential contribution of increasing breastfeeding rates
in the UK. Commissioned by UNICEF UK; 2012.
www.greenwichbreastfeeding.com/media/1612/preventing_disease_sa
ving_resources_policy_doc-1.pdf
19 Jegier BJ, Johnson TJ, Engstrom JL et al. The institutional cost of
acquiring 100 ml of human milk for very low birth weight infants in the
49
neonatal intensive care unit. Journal of Human Lactation 2013, 29:3.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4608232
20 Rice SJC, Craig D, McCormick F et al. Economic evaluation of
enhanced staff contact for the promotion of breastfeeding for low birth
weight infants. International Journal of Technology Assessment in
Health Care 2010, 26(2):133–140.
www.cambridge.org/core/journals/international-journal-of-technology-
assessment-in-health-care/article/economic-evaluation-of-enhanced-
staff-contact-for-the-promotion-of-breastfeeding-for-low-birth-weight-
infants/9BABC06CE07FD8DB667255BF56E72612
21 Parker LA, Krueger C, Sullivan S et al. Effect of breast milk on hospital
costs and length of stay among very low birth weight infants in the
NICU. Advances in Neonatal Care 2012, 12(4):254–259.
www.ncbi.nlm.nih.gov/pubmed/22864006
22 Cricco-Lizza R. Rooting for the breast: breastfeeding promotion in the
NICU. The American Journal of Maternal Child Nursing 2009,
34(6):356–64. www.ncbi.nlm.nih.gov/pubmed/19901697
23 Quigley M and McGuire W. Formula versus donor breast milk for
feeding preterm or low birth weight infants. Cochrane Database of
Systematic Reviews 2014, Issue 4.
http://onlinelibrary.wiley.com/wol1/doi/10.1002/14651858.CD002971.pu
b3/abstract
24 Arslanoglu S, Ziegler EE and Moro GE. Donor human milk in preterm
infant feeding: evidence and recommendations. Journal of Perinatal
Medicine 2010, 38(4):347–51.
www.ncbi.nlm.nih.gov/pubmed/20443660
25 Conde-Agudelo A and Díaz-Rossello JL. Kangaroo mother care to
reduce morbidity and mortality in low birthweight infants (Review).
50
Cochrane Database of Systematic Reviews 2016, Issue 8.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002771.pub4/a
bstract
26 Renfrew MJ, Craig D, Dyson L et al. Breastfeeding promotion for
infants in neonatal units: a systematic review and economic analysis.
Health Technology Assessment 2009, 13(40):1–146.
www.ncbi.nlm.nih.gov/pubmed/19728934
27 Lawn JE, Mwansa-Kambafwile J, Horta BL et al. ‘Kangaroo mother
care’ to prevent neonatal deaths due to preterm birth complications.
International Journal of Epidemiology 2010, 39:i144–i154.
www.ncbi.nlm.nih.gov/pmc/articles/PMC2845870
51
Appendix 1: Guide to the Baby Friendly Initiative standards (UNICEF, December 2012). These standards incorporate the previous standards as specified in the Ten
Steps to Successful Breastfeeding and Seven Point Plan for Sustaining
Breastfeeding in the Community, but update and expand them to fully reflect
the evidence base on delivering the best outcomes for mothers and babies in
the UK: www.unicef.org.uk/wp-
content/uploads/sites/2/2014/02/Baby_Friendly_guidance_2012.pdf
In relation to breastfeeding/breast milk feeding in neonatal units, the following
standards (reproduced verbatim) will need to be met in order to be successful
at Stage 3 [UNICEF, BFI] assessment.
1. Support parents to have a close and loving relationship
with their baby
You will know that the facility has met this standard when:
• Parents have a discussion with an appropriate member of staff as soon
as possible about the importance of touch, comfort and communication
for their baby’s health and development.
• Parents are actively encouraged to provide comfort and emotional
support for their baby including prolonged skin contact, comforting
touch and responsiveness to their baby’s behavioural cues.
We will assess this by:
• Verification of the current systems by which:
o Parents have a discussion about touch, comfort and responding to
behavioural cues as soon as possible.
• Reviewing:
52
o Information provided for parents on the importance of touch,
comfort and responding to behavioural cues and skin-to-skin
contact.
o Internal audit results that relate to this standard.
• Listening to mothers and asking them about their experiences of:
o Encouragement to touch, comfort and respond to their baby.
o Skin-to-skin contact and kangaroo care.
Guidance
The aim of this standard is to ensure that a positive parent/baby relationship is
recognised as being crucial to the wellbeing and development of babies. In
order for this to happen, parents should be encouraged to be with their baby
for as long as, and as often as, they wish. They should be supported to
comfort and respond to their baby’s needs by communicating with and
touching their baby as appropriate to their condition.
It is expected that skin-to-skin contact and/or kangaroo care will be
encouraged as part of the developmental care package, and that local
guidelines to ensure best practice regarding frequency and duration of skin
contact will be available.
It is suggested that parents are provided with a personal log or diary to record
their daily observations and interactions with their baby including touch,
comfort holding and skin-to-skin contact.
• Read UNICEF UK’s advice on their skin-to-skin contact page
• Find out about Best Beginnings' Small Wonders DVD
• Order Bliss' free Skin-to-Skin booklet
• Order Bliss’ free booklet on watching and understanding your
premature baby
53
If a mother chooses to bottle feed, skin contact/kangaroo care is important for
them to develop close and loving bonds with the baby. When their baby is
developmentally ready to bottle feed they should be taught to hold their baby
close and offer feeds in a responsive way that follows the baby’s lead.
Premature babies can sometimes find bottle feeding stressful, as they have
little control over the milk flow, and can struggle to protect their airway if the
flow is too rapid. Parents should be supported to recognise the cues for a
need for pacing, such as by removing the teat at frequent intervals to allow
the baby to rest during feeds.
See UNICEF's webpage on bottle feeding for further information.
2. Enable babies to receive breast milk and to breastfeed
when possible
You will know that the facility has met this standard when:
• A mother’s own breastmilk is always the first choice of feed for her
baby.
• Mothers have a discussion regarding the importance of their breastmilk
for their preterm or ill babies as soon as is appropriate.
• Mothers are enabled to express breastmilk for their baby, including
support to:
o express as early as possible after birth (ideally within six hours).
o learn how to express effectively, including hand expression, use of
breast pump equipment and storing milk safely.
o express frequently, especially in the first two to three weeks
following delivery, in order to optimise long-term milk supply.
o stay close to their baby when expressing milk.
o access effective breast pump equipment.
o access further help with expressing if milk supplies are inadequate,
or if less than 750 ml in 24 hours by day 10.
54
o use their milk for mouth care when their baby is not tolerating oral
feeds, and later to tempt their baby to feed.
• In the unit there is evidence that:
o a suitable environment conducive to effective expression is created.
o a formal review of expressing is undertaken a minimum of four
times in the first two weeks to support optimum expressing and milk
supply.
o appropriate interventions are implemented to overcome
breastfeeding/expressing difficulties where necessary.
• Mothers receive care that supports the transition to breastfeeding,
including:
o being able to be close to their baby as often as possible so that they
can respond to feeding cues.
o use of skin-to-skin contact to encourage instinctive feeding
behaviour.
o information about positioning for feeding and how to recognise
effective feeding.
o additional support to help with breastfeeding/expressing challenges
when needed.
• Mothers are prepared to feed and care for their baby after discharge
from hospital, including:
o having the opportunity to stay overnight or for extended periods to
support development of the mother’s confidence and modified
responsive feeding
o information about how to access support in the community.
• There is no advertising for breast milk substitutes, bottles, teats or
dummies anywhere in the service or by any of the staff.
We will assess this by:
• Verification of the current systems by which:
o mothers are informed about the importance of their breast milk.
55
o mothers are encouraged to express, including availability of
equipment, how milk is stored and information about expressing
(including frequency of expressing, night time expressing and
enabling mothers to be close to their baby when expressing their
breast milk).
o a formal expressing assessment is carried out a minimum of four
times in the first two weeks.
o mothers receive care that supports the transition to breastfeeding.
o additional support with breastfeeding is provided when needed.
o mothers are prepared for discharge home with their baby, including
facilities available for staying overnight/for extended periods.
o mothers are informed about local support available after discharge.
• Reviewing:
o Information provided for parents.
o Internal audit results about parents’ experiences of care.
o Internal processes for loaning/hiring expressing equipment.
o Breast milk storage standards.
o Breastfeeding statistics including use of mothers’ own breast milk,
use of all breast milk, use of breast milk on discharge and rates of
exclusive/any breastfeeding on discharge.
o The hospital environment to ensure that there is no advertising of
breast milk substitutes, bottles, teats or dummies.
• Listening to mothers with babies who have been discharged from the
unit to find out about their experiences of:
o expressing breast milk.
o establishing breastfeeding.
o preparing to go home with their baby.
Guidance
The aim of this standard is to ensure that mothers of sick and preterm babies
are supported to initiate and maintain lactation so that they can provide breast
56
milk for their baby and make a successful transition to breastfeeding. It is
important that, where possible, a mother’s own breast milk is the first choice
of feed for her baby. Where a mother’s breast milk is not available,
appropriate use of donor milk should be considered as the second choice.
For sick and preterm babies the importance of breast milk cannot be
overestimated. Human milk supports growth, provides protection from
infection and is linked to reductions in mortality and morbidity. In particular,
evidence suggests that the use of breast milk decreases the incidence and
severity of the life threatening disease necrotising enterocolitis. It is therefore
important that mothers, partners and their family understand this to allow
informed decision making in the best interests of the baby.
Expressing breast milk
Mothers should be shown how to express their breast milk as soon as
possible and certainly within six hours of birth. Thereafter they should be
supported to express a minimum of eight times in 24 hours, including once
during the night. Early and frequent expressing is vital if the immature
glandular tissue is to be effectively programmed so that the mother has the
potential to produce enough milk for her baby. Hand expressing is effective for
obtaining colostrum, but mothers should be taught how to use an electric
breast pump as the volume of milk increases to 5–7 ml per expression. Hand
expressing can still be used in conjunction with pumping if the mother wishes.
Good liaison between staff in the maternity and neonatal unit is important to
ensure that mothers are supported to express early, frequently and effectively.
It is recommended that an individual expressing log is provided to all mothers
to help them record frequency of expression and increases in volumes of milk
expressed. In recognition of the challenges faced by mothers to sustain
frequent expressions, it is expected that staff will review expressing progress
at least four times during the first two weeks to ensure an effective technique
and to monitor milk volumes. See UNICEF's document for the assessment of
57
breastmilk expression (www.unicef.org.uk/babyfriendly/baby-friendly-
resources/guidance-for-health-professionals/tools-and-forms-for-health-
professionals/checklist-for-assessment-of-breastmilk-expression) for more
information.
With effective expression a mother can aim to achieve an approximate daily
volume of 750 ml of breast milk at two weeks. Mothers do not need to adhere
to a strict regime when expressing, but should be advised not to leave gaps
longer than four hours in the day and six hours at night between expressions.
Skin-to-skin contact should be encouraged to help boost milk-producing
hormones and to encourage pre-feeding behaviour, such as licking and
nuzzling at the breast.
Transition to breastfeeding
Mothers should be supported to make the transition to breastfeeding when the
baby shows signs of developmental readiness. However, staff can encourage
mothers to practice the principles of positioning at any time, so that they
develop confidence and are alert to early feeding cues and signs of readiness.
Where possible, avoidance of teats and dummies while the baby is learning to
breastfeed may assist with a smoother transition. See Best Beginnings'
information on their Small Wonders DVD and the Yorkshire and Humber
Health Innovation and Education Cluster.
It is expected that all breastfeeding mothers will have access to specialist
support with expression and breastfeeding at all times during their stay in the
unit. They should also be provided with details of voluntary support for
breastfeeding which they can choose to access at any time during their baby’s
stay.
Preparation for discharge should begin at admission, and parents should be
supported to provide increasing amounts of care for their baby at the earliest
opportunity. Parents should also have the opportunity to stay overnight and
58
care for their baby independently prior to discharge home. At this time it is
important that parents are encouraged to respond to their baby’s needs for
feeding and comfort and, as part of the preparation for discharge, discussions
should be had on the importance of moving towards a less regimented
feeding plan.
It is expected that the unit will collect breastfeeding rates on discharge in an
effort to demonstrate ongoing improvements in care and support provided.
(See the Department of Health’s Toolkit for High Quality Neonatal Services at
webarchive.nationalarchives.gov.uk/20130103004816/http://www.dh.gov.uk/pr
od_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@perf/docume
nts/digitalasset/dh_108435.pdf)
The prospect of caring for their baby at home after a long period in a neonatal
unit can be a major cause of anxiety in parents. It is therefore important to
provide them with details of where they can access support within the
community. If an outreach service is not provided, staff in the unit should liaise
with other health professionals such as the health visiting team to ensure that
parents are supported after discharge.
Information on specific support groups (such as Bliss) should also be
provided.
3. Value parents as partners in care
You will know that the facility has met this standard when:
• All parents have unrestricted access to their baby unless individual
restrictions can be justified in the baby’s best interest.
• The unit makes being with their baby as comfortable as possible for
parents (for example, by creating a welcoming atmosphere, putting
comfortable chairs by the side of each cot, giving privacy when needed
or providing facilities for parents to stay overnight).
• Staff enable parents to be fully involved in their baby’s care.
59
• Every effort is made to ensure effective communication between the
family and the health care team (including listening to parents’ feelings,
wishes and observations).
We will assess this by:
• Verification of the current systems by which:
o parents have unrestricted access to their baby.
o staff enable parents to be involved in the care of their baby.
o effective communication is supported throughout the unit.
o parents’ emotional needs are addressed.
• Reviewing:
o The facilities on the unit for making parents comfortable.
o Internal audit results about parents’ experiences of care.
• Listening to mothers to find out about their experiences of care,
including:
o access to their baby.
o how they were involved in their baby’s care.
o what methods staff used to communicate with them.
o the facilities on the unit to make their stay comfortable.
o whether mothers who formula feed received information about how
to clean/sterilise equipment, make up a bottle of formula milk and
feed this to their baby using a safe technique.
Guidance
The aim of this standard is to enable staff working within neonatal units to
create an environment whereby parents are valued for their contribution to the
wellbeing of their baby.
60
Hospital routines should not be deemed as more important than parents for
babies’ wellbeing; parents should only ever be denied access to their baby on
occasions where it is judged to be in the baby’s best interest.
Staff training and unit guidelines should outline ways in which parents are
made to feel welcome, needed and safe when they are on the unit.
Good communication is essential if parents are to be fully engaged with their
baby’s progress, and staff should ensure that they provide clear, regular
updates for parents. Families may be in the neonatal unit for weeks or even
months; the relationship they build with the staff who care for their baby is
therefore important to them, and has been shown to help alleviate stress.
Staff caring for a baby should keep in mind that the baby is part of a wider
family, and that supporting family-centred care will result in better outcomes
for all. Ensuring that staff take time to talk to parents about the impact on their
lives of having a baby in the unit is important.
See the Department of Health’s Toolkit for High Quality Neonatal Services:
webarchive.nationalarchives.gov.uk/20130103004816/http://www.dh.gov.uk/pr
od_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/@sta/@perf/docume
nts/digitalasset/dh_108435.pdf
See the Bliss Baby Charter Standards:
www.nornet.org.uk/resources/Documents/BLISS%20Baby%20Charter%20Sta
ndards.pdf
The provision of comfortable chairs close to their baby will encourage parents
to spend more time with the baby, and enable them to rest during their time in
the unit. The unit should provide simple facilities where parents can go to
meet with other parents, or take time out to have something to eat or drink –
this has been recognised as important for parents.
Supporting parents in care-giving activities from the very start is recognised
as best practice, and has a positive impact on confidence and family
61
relationships. Parents will have the baby’s best interest at heart and will often
be the most vigilant when it comes to picking up on subtle changes in their
baby’s condition. It is therefore essential that they are respected, listened to
and valued as partners in working to achieve the very best outcomes possible
for the baby.
For the reader’s convenience, please also see the following:
• UNICEF Baby Friendly conference: Taking neonatal care to the next
level (London, May 2015):
www.unicef.org.uk/babyfriendly/baby-friendly-neonatal-special-qa-dr-
nils-bergman
• The UNICEF Neonatal Standards:
www.unicef.org.uk/BabyFriendly/Resources/Guidance-for-Health-
Professionals/Writing-policies-and-guidelines/guide-to-the-baby-
friendly-initiative-standards
• In addition, the evidence that underpins the neonatal standards can be
found in Chapter 5 of ‘The evidence and rationale for the UNICEF UK
Baby Friendly Initiative standards’: www.unicef.org.uk/wp-
content/uploads/sites/2/2013/09/baby_friendly_evidence_rationale.pdf
62
Appendix 2: Support for family-centred care
As defined in the Poppy Steering Group Report (2009)5, the family-centred
model emphasises that the relationship between parents and health care
professionals should be one of equals, with staff respecting parents’ unique
role as the baby’s family and aiming to enable them to be fully involved with
their baby’s care.
Some clinical decisions will be made when there is no time for explanations or
discussion, or when the parents are not present, but every effort should be
made to keep parents informed and to consult them.
It should be remembered that the baby is born into a family and the neonatal
unit is working for the baby’s health and wellbeing and for the wellbeing of the
whole family. Practical support and involving parents in their baby’s care
assists confidence-building in the early days and can give some measure of
control when a parent may be feeling powerless.
As babies grow and milk feeding is established, opportunities for parents to
care for their baby increase and begin to prepare for going home.
63
Practical support is particularly important during times of transition and when
parents are expected to take increasing responsibility in caring for their still
small and vulnerable baby.
Parents’ closeness to and involvement with their baby can be supported
through encouraging:
• positive reassuring touch
• comfort or containment holding
• skin-to-skin or ‘kangaroo’ care
• nappy changing and providing other care
• expressing breast milk
• giving milk feeds.
Key elements of family-centred care
Key elements of family-centred care in response to premature babies and
their families are listed as follows:
• Recognising and valuing the roles of parents, siblings and other family
members.
• Developing awareness of parents’ needs, the emotional impact of
preterm birth and individual differences in parental responses and
needs.
• Recognising critical steps for parents on the care pathway.
• Maximising opportunities for communication with parents and local
community groups.
• Providing practical help with infant care and parent interaction,
including behavioural cues.
• Increasing confidence in role as a parent and supporting the parent–
infant relationship.
• Providing psychosocial support.
• Valuing and supporting mothers’ ability to nurture their baby through
expressing breast milk and breastfeeding.
64
• Providing appropriate family-friendly facilities.
Family-friendly facilities in neonatal care
Appropriate facilities for parents and families in or near the neonatal unit will
enable parents to visit, stay during the day and to feel welcome in doing so.
It is important for mothers to have good facilities to enable them to express
breast milk frequently and feed their baby. These should be available both in
a comfortable, private room but also by their baby’s incubator or cot, as they
may want to stay close to their babies as close proximity enhances the
let-down reflex.
Availability of milk from a human milk bank is important, especially for families
with twins or more babies, for mothers who are too ill to express or babies
undergoing surgery and likely to need expressed milk.
Responsibility for family-centred neonatal care
Those responsible for enabling family-centred neonatal care include:
• All health care professionals working in neonatal care and those
working with babies and their families after discharge home.
• Individual practitioners, with specific roles and duties such as
breastfeeding support, home visiting, and bereavement care.
• The organisation (PCT, board, hospital trust and individual unit)*
responsible for providing care, with parent and family-oriented policies,
training and education.
• Neonatal networks and other organisations or groups commissioning
and planning the provision and organisation of care.
* In Scotland the organisation would refer to Health Boards.
65
In addition to this definition, a link to the presentation at the UNICEF Neonatal
Conference held in London on 19 May 2015 is provided here:
www.unicef.org.uk/babyfriendly/wp-
content/uploads/sites/2/2014/10/Shoo_Lee_FIC_conf_2015.pdf